County of Santa Clara Emergency Medical Services System Policy #700-M12: Continuous Positive Airway Pressure CONTINUOUS POSITIVE AIRWAY PRESSURE Effective: February 8, 2013TBD Replaces: NewFebruary 8, 2013 Review: November 2014TBD I. Purpose The purpose of this policy is to describe the process of initiating and managing continuous positive airway pressure (CPAP) to patients and required equipment. A. Goals of CPAP 1. Normally the patient should improve in the first five minutes of CPAP. Signs of improvement include: a. Elimination of dyspnea b. Decreased respiratory rate c. Decreased heart rate d. Increased SpO2 e. Stabilized BP 2. Should the patient fail to improve with CPAP, remove the CPAP device and assist ventilations with BVM or intubate patient. Signs and symptoms of failure to improve include the following: a. Sustained or increased heart rate b. Sustained or increased respiratory rate c. Sustained or increased BP d. Sustained or decreasing pulse oximetry readings, and/or e. Decreased level of consciousness II. Definitions Introduction Prehospital CPAP treatment in patients with Acute Pulmonary Edema can improve oxygenation significantly and lower respiratory rate, heart rate, and systolic blood pressure. Continuous positive airway pressure (CPAP) may reduce the need for intubation and mechanical ventilation in patients with acute hypoxemic respiratory insufficiency. Noninvasive ventilation (NIV) has been associated with lower rates of endotracheal intubation in populations of patients with acute respiratory failure. Page 1 of 4
III. Indications A. CPAP is indicated for patients in severe respiratory distress that meet the following criteria: 1. The patient is 8 years old or greater and: a. There is a medical history of CHF with pulmonary edema with one or more of the following present: 1) Pedal edema 2) Orthopnea (SOB while lying supine) 3) Anxiety 4) Diaphoresis (perfuse sweating) 5) Current prescription of Digoxin of Lasix 6) Sudden onset of SOB Or b. The patient displays signs and symptoms of: 1) Severe asthma attack 2) COPD exacerbation 3) Near drowning 4) Severe respiratory distress B. CPAP is indicated for patients in severe respiratory distress with a DNR/POLST form that stipulates comfort care. Indications Age > 8 years old. History of CHF with Pulmonary Edema and one or more of the following: o Pedal Edema. o Taking Digoxin or Lasix. o Orthopnea. o Severe or sudden onset SOB. o Anxious. o Rales or coarse wheezes. o Diaphoresis. o Hypertension. OR Near Drowning. Severe respiratory distress. IV. Contraindications Contraindications A. Absolute Contraindications (DO NOT USE): Page 2 of 4
o1. Age is <less than 8 years old o2. Respiratory or cardiac arrest o3. Agonal respiration o4. Severely depressed level of consciousness o5. Systolic BP <is less than 90 mmhg o6. Signs and symptoms of pneumothorax o7. Inability to maintain airway patency o8. Major trauma, especially head injury with increased ICP or significant chest trauma o9. Facial anomalies or trauma (e.g., burns, fractures) o10. Patients that have an increased risk of aspirationvomiting B. Relative contraindications (USE CAUTIOUSLY): o1. History of pulmonary fibrosis o2. Decreased LOC o3. Claustrophobia or unable to tolerate mask (after first 1-2 minutes trial) V. Equipment A. Santa Clara County approved CPAP delivery system Equipment Boussignac CPAP system. Oxygen tank with flow rate regulator that can achieve 25 l/min (25 LPM flow will achieve CPAP of 8-10 cm H2O). VI. Procedure Procedure A. Place patient in a seated position with legs dependent. Monitor ECGVS (BP, HR, RR, SpO2) B. Apply the county approved CPAP mask/device to the patient Attach hose to an O2 tank capable of 25 LPM flow rate and place mask on patient. A liter flow of 25 LPM will provide approximately 8-10 cm of water pressure. C. Provide patient reassurance. that tthis will assist to alleviate breathing problems. D. If indicated, NTG spray can be given through the open port, or simply remove the mask long enough to spray. E. Indicate that CPAP is being used when giving the ring down report so the ED can be ready to maintain the procedure on arrival to ED. F. Monitor ECG and v/s (including: BP, HR, RR, SpO2), every five (5) minutes. Page 3 of 4
G. If there is no improvement in v/s or mentation within five (5) minutes, consider the need for an advanced airway and discontinue CPAP. H. Documentation shall include ECG, v/s, patient s response to treatment, and any adverse event related to treatment. VII. Complications Complications A. Hypotension. B. C. Pneumothorax. Corneal drying. Goals of CPAP Normally the patient should improve in the first five minutes of CPAP. Signs of improvement include: Elimination of dyspnea. Decreased respiratory rate. Decreased heart rate. Increased SpO2. Stabilized BP. Failure to improve Should the patient fail to improve with CPAP, remove the CPAP device and assist ventilations with BVM or intubate patient. Signs and symptoms of failure to improve include the following: Sustained or increased heart rate. Sustained or increased respiratory rate. Sustained or increased BP. Sustained or decreasing pulse oximetry readings, and/or Decreased level of consciousness. Documentation The use of CPAP must be documented on the PCR. VS (BP, HR, RR and SpO2) must be documented every 5 minutes. In the narrative section of the PCR, document the patient s response to CPAP. Any adverse event related to the use of CPAP. Indicate that CPAP is being used when giving the ring down report so the ED can be ready to maintain the procedure on arrival to the ED. Page 4 of 4
County of Santa Clara Emergency Medical Services System Policy #700-M12: Continuous Positive Airway Pressure CONTINUOUS POSITIVE AIRWAY PRESSURE Effective: February 12, 2015 Replaces: February 8, 2013 Review: November 12, 2017 I. Purpose The purpose of this policy is to describe the process of initiating and managing continuous positive airway pressure (CPAP) to patients and required equipment. A. Goals of CPAP 1. Normally the patient should improve in the first five minutes of CPAP. Signs of improvement include: a. Elimination of dyspnea b. Decreased respiratory rate c. Decreased heart rate d. Increased SpO2 e. Stabilized BP 2. Should the patient fail to improve with CPAP, remove the CPAP device and assist ventilations with BVM or intubate patient. Signs and symptoms of failure to improve include the following: a. Sustained or increased heart rate b. Sustained or increased respiratory rate c. Sustained or increased BP d. Sustained or decreasing pulse oximetry readings, and/or e. Decreased level of consciousness II. Definitions Prehospital CPAP treatment in patients with Acute Pulmonary Edema can improve oxygenation significantly and lower respiratory rate, heart rate, and systolic blood pressure. Continuous positive airway pressure (CPAP) may reduce the need for intubation and mechanical ventilation in patients with acute hypoxemic respiratory insufficiency. Noninvasive ventilation (NIV) has been associated with lower rates of endotracheal intubation in populations of patients with acute respiratory failure. Page 1 of 3
III. Indications A. CPAP is indicated for patients in severe respiratory distress that meet the following criteria: 1. The patient is 8 years old or greater and: a. There is a medical history of CHF with pulmonary edema with one or more of the following present: 1) Pedal edema 2) Orthopnea (SOB while lying supine) 3) Anxiety 4) Diaphoresis (perfuse sweating) 5) Current prescription of Digoxin of Lasix 6) Sudden onset of SOB Or b. The patient displays signs and symptoms of: 1) Severe asthma attack 2) COPD exacerbation 3) Near drowning 4) Severe respiratory distress B. CPAP is indicated for patients in severe respiratory distress with a DNR/POLST form that stipulates comfort care. IV. Contraindications A. Absolute Contraindications (DO NOT USE): 1. Age is less than 8 years old 2. Respiratory or cardiac arrest 3. Agonal respiration 4. Severely depressed level of consciousness 5. Systolic BP is less than 90 mmhg 6. Signs and symptoms of pneumothorax 7. Inability to maintain airway patency 8. Major trauma, especially head injury with increased ICP or significant chest trauma 9. Facial anomalies or trauma (e.g., burns, fractures) 10. Patients that have an increased risk of aspiration B. Relative contraindications (USE CAUTIOUSLY): 1. History of pulmonary fibrosis 2. Decreased LOC 3. Claustrophobia or unable to tolerate mask (after first 1-2 minutes) Page 2 of 3
V. Equipment A. Santa Clara County approved CPAP delivery system VI. Procedure A. Place patient in a seated position with legs dependent. B. Apply the county approved CPAP mask/device to the patient C. Provide patient reassurance. This will assist to alleviate breathing problems. D. If indicated, NTG spray can be given through the open port, or simply remove the mask long enough to spray. E. Indicate that CPAP is being used when giving the ring down report so the ED can be ready to maintain the procedure on arrival to ED. F. Monitor ECG and v/s (including: BP, HR, RR, SpO2), every five (5) minutes. G. If there is no improvement in v/s or mentation within five (5) minutes, consider the need for an advanced airway and discontinue CPAP. H. Documentation shall include ECG, v/s, patient s response to treatment, and any adverse event related to treatment. VII. Complications A. Hypotension. B. Pneumothorax. C. Corneal drying. Page 3 of 3